1104008879 NPI number — OUTREACH PROFESSIONAL SERVICES INC

Table of content: (NPI 1104008879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104008879 NPI number — OUTREACH PROFESSIONAL SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OUTREACH PROFESSIONAL SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104008879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26908 DETROIT RD
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44145-2398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-617-1823
Provider Business Mailing Address Fax Number:
440-617-0884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11201 SHAKER BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-721-6900
Provider Business Practice Location Address Fax Number:
216-368-7905
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLAYLOCK
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
440-892-6406

Provider Taxonomy Codes

  • Taxonomy code: 207RG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0251856 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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